Clinical Review Clinician – Appeals

This is a fully remote position, open to applicants in Florida, +16 more locations.

📋 Description

• Conduct clinical assessments necessary to resolve and process appeals.

• Examine medical records and clinical data to ascertain medical necessity in line with policies, guidelines, and NCQA standards.

• Prepare case evaluations for Medical Directors by investigating appeals, reviewing relevant criteria, and assessing the grounds for appeals.

• Ensure that reviews, processing, and responses to appeals are conducted promptly in compliance with State, Federal, and NCQA standards.

• Engage with members, providers, facilities, and other departments regarding appeal requests.

• Create suitable communication and reporting related to appeals resolutions for members and providers.

• Collaborate with leadership to enhance the consistency, efficiency, and appropriateness of responses to appeal requests.

• Partner with interdepartmental teams to refine clinical appeals processes and procedures, and to prevent recurrences by adhering to industry best practices.

• Carry out other assigned duties as necessary.

• Adhere to all policies and standards.

⛳️ Requirements

• Degree from an accredited nursing program or a Master’s degree in Behavioral Health or Social Work.

• 2–4 years of relevant experience.

• Licensed in MI, NV, or IL, and/or possess a compact license.

• Required licensure: LPN, LVN, RN (state and/or compact), LCSW, LMHC, LPC, LMFT, or Licensed Psychologist.

• Preferred knowledge of NCQA, Medicare, and Medicaid regulations.

• Preferred understanding of utilization management processes.

• Competence in utilizing company policies and clinical decision-making tools, such as InterQual.

• Capability to analyze data from multiple systems.

• Ability to thrive in a fast-paced Appeals environment.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement program.

• Paid time off along with holidays.

• Flexible work arrangements, including remote, hybrid, field, or office schedules.